The role of curriculum

In comparison to postgraduate training, undergraduate training is felt to be much less prescriptive.

I think as long as the feedback that we’re getting back is good, we’re…not left on our own, but we’re allowed to do it our way. (M5) I also think…it's not as regulation bound as it the ST training…I can’t really be bothered with hoop jumping. (M10)

This comparatively “lighter touch” approach is welcomed by many supervisors, particularly those who have been postgraduate trainers in the past.

I'm less hide bound by the rules than my postgraduate training colleagues because they have a much more prescribed curriculum. One of the joys of the undergraduate curriculum for me is that I can, largely speaking, be left to my own devices. I'm not told what to do nearly to the same extent and I don’t also have to spend hours online completing assessment forms… I'm not sure I could cope with being a trainer now because it's just, for me, it's far too controlled. (M1)

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While several interviewees appreciated the feeling of being trusted to provide teaching as long as their feedback is ok and the flexibility this afforded, this was not the case for all. A newer tutor described the challenge of knowing how you are doing as a tutor in practice, physically separated from the University:

I think probably you just kind of pedal along assuming you are doing much what everybody else is doing but not really knowing. (M4)

This uncertainty was not exclusive to the newer tutors, as illustrated in this comment from one of the most experienced tutors.

I remember asking SENIOR MEDICAL SCHOOL FIGURE what exactly it was that we were meant to be teaching. And he said ‘Well, as the students all give you good feedback, what you are doing is obviously fine’. I thought that was a bit less than helpful. (M10)

As discussed in 3.4.3, there is not a national curriculum for teaching in General Practice. The lack of a specific curriculum is appreciated by some tutors and frustrating to others. To guide students, our medical school does produce a master list of clinical presentations for the senior medical students to use. (Appendix X)

Similarly, although there is a broad Foundation Curriculum, there is not a

specific curriculum for GP which results in variation in what teachers think they are to teach. One tutor describes having created his own curriculum to fill this void for his foundation trainees.

I’ve sort of invented a curriculum for FY2…I tell them that the 3 things I want them to do. [The first] is to learn how to do a consultation which I think is a generic skill, not just for general practice, but one very poorly practiced on a great deal of people out with general practice. [The second is] that I want them to be comfortable working to the limit of, but within, their capabilities. And [the third] thing that we have been told we’ve to do is long term condition

management so I teach them long term condition management. (M10) In contrast to the lack of an undergraduate curriculum, there is a clear and thorough curriculum for GP training. Despite this, direct use of the GP

curriculum only arose in one interview. Its indirect use was implied in several ways, particularly when considering the various assessment requirements required to be undertaken by the trainees as part of the Work Placed Based

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Assessment (WPBA) component of the MRCGP tripos. These are then recorded within their e portfolio.

Overall, reviewing respondents’ descriptions of what they believed they were expected to teach or should be teaching, a huge variation was noted. All interviewees reported tailoring learning to their individual learners’ needs and interests and the flexibility afforded by the lack of a prescribed curriculum seemed to support them to do this. This ethos of tailoring learning opportunities to the individual will be explored in 7.6.3

Across both undergraduate and postgraduate, but particularly postgraduate, there was a feeling that the assessments were driving the teaching content. In some ways, a lack of a prescribed undergraduate curriculum gave the tutors the freedom to deliver a curriculum they felt suited individual students needs or addressed areas they personally felt were underrepresented in the medical school curriculum (e.g. prescribing, doctor as activist). The downside of this is that the variability of content may be considered a concern. (See Table 7-2, Table 7-3 and Table 7-4)

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Table 7-2 GPs perceptions of what to teach - postgraduate

Table 7-3GPs perceptions of what to teach - undergraduate

What to Teach Postgraduate

Clinical examination skills

Team working in GP - in particular that they are not working in isolation Gaps in training (eg identified from posts, rating scales, e portfolio entries

Preparing to work as a GP in practice (eg managing workload, running a business, doing polypharmacy reviews) Quality Improvement Activity - audit, SEA

Research

Preparation for exams eg CSA Assessment tools - CbDs, CoTs

Soft stuff' - communication skills and ethics Consultation Skills

Comfortable working within capabilities Long term condition management

Program of tutorials 'want ticked off early on' and often 'near the end' too Clinical teaching based on areas expertise

Focused investigation and appropriate use of resources

What to Teach - Undergraduate

Teaching for assessment eg OSCE prep, clinical skills

Clinical medicine eg common GP diagnoses, 'non-medical' presentations 'Everyday life'

Tailor attachment to what they want to do Team working - breadth of clinical team

About General Practice in their practice context eg rural, deprived, multicultural Consulting - student led surgeries and consultation theory

Prescribing and limitations of protocols

Lifelong learning - ask questions if don’t know something, ok to make mistakes and not know everything Focused history and examination

Principles of community based medicine and the role of the GP

What individual perceives is missing from or inadequately taught in medical school curriculum eg prescrbing , risk, dr as advocate Ok to reassure if self limiting illness

Attitudinal - building confidence or teaching humility as needed Clinical courage to challenge if feel something not right Patient- centredness - teaching about life as a patient Going beyond history and examination

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Table 7-4 GPs perception of what to teach - common to undergraduate and postgraduate

7.4.3.1 Activity Theory interpretation

AT describes how the challenge of boundary crossing directly impacts on teaching in practices by identifying the tensions which arise through the variation in curricula and different organisational approaches to teaching content. The different undergraduate and postgraduate organisations are represented as their own activity systems with their own tools (e.g. curricula, master list of conditions) which can function as boundary objects. The

difference in curricula can be represented as a quaternary contradiction (Figure 7-8). Although different rules may be seen between organisations, the

underpinning value of learner-centred teaching was common to all and could be conceptualised as both a rule and a tool of teaching.

What to teach - Common to both Undergraduate and Postgraduate

Principles of lifelong learning Teaching to reflect

Cultural norms if international students or graduates

Doctor in Society - Social accountability, doctor as activist, health inequalities Sharing uncertainty with colleagues

Generalism and personal doctoring Work life balance

Holistic care

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Figure 7-8 The role of curriculum in undergraduate and postgraduate GP education